Beruflich Dokumente
Kultur Dokumente
AIDS TO THE
EXAMINATION
OF THE PERIPHERAL
NERVOUS SYSTEM
W.B.SAUNDERS
EDINBURGH • LONDON - NEW YORK • PHILADELPHIA • STLOUIS • SYDNEY • TORONIO 2000
W. B. SAUNDERS
An imprint of Harcourt Publishers Limited
Printed in China
GCC/01
In 1940 Dr George Riddoch was Consultant Neurologist to the Army. He realised the
necessity of providing centres to deal with peripheral nerve injuries during the war. In
collaboration with Professor J. R. Learmonth, Professor of Surgery at the University of
Edinburgh, peripheral nerve injury centres were established at Gogarburn near
Edinburgh and at Killearn near Glasgow. Professor Learmonth wished to have an
illustrated guide on peripheral nerve injuries for the use of surgeons working in general
hospitals. In collaboration with Dr Ritchie Russell, a few photographs demonstrating the
testing of individual muscles were taken in 1941. Dr Ritchie Russell returned to Oxford in
1942 and was replaced by Dr M. J. McArdle as Neurologist to Scottish Command. The
photographs were completed by Dr McArdle at Gogarburn with the help of the
Department of Medical Illustration at the University of Edinburgh. About twenty copies in
loose-leaf form were circulated to surgeons in Scotland.
In 1943 Professor Learmonth and Dr Riddoch added the diagrams illustrating the
innervation of muscles by various peripheral nerves modified from Pitres and Testut,
(Les Neufs en Schemas, Doin, Paris, 1925) and also the diagrams of cutaneous sensory
distributions and dermatomes. This work was published by the Medical Research
Council in 1943 as Aids to the Investigation of Peripheral Nerve Injuries (War Memorandum
No. 7). It became a standard work and over the next thirty years many thousands of
copies were printed.
It was thoroughly revised between 1972 and 1975 with new photographs and many new
diagrams and was republished under the title Aids to the Examination of the Peripheral
Nervous System (Memorandum No. 45). reflecting the wide use made of this booklet by
students and practitioners and its more extensive use in clinical neurology, which was
rather different from the war time emphasis on nerve injuries.
In 1984 the Medical Research Council transferred responsibility for this publication to
the Guarantors of Brain for whom a new edition was prepared. Modifications were made to
some of the diagrams and a new diagram of the lumbosacral plexus was included.
Most of the photographs for the 1943. 1975 and 1986 editions show Dr McArdle, who
died in 1989, as the examining physician. A new set of colour photographs has been
prepared for this edition, the diagrams of the brachial plexus and lumbosacral plexus have
been retained, but all the other diagrams have been redrawn.
ACKNOWLEDGEMENTS
Patricia Archer PhD for the drawings of the brachial plexus and lumbosacral plexus
Ralph Hutchings for the photography
Paul Richardson for the artwork and diagrams
Michael Hutchinson MB BDS for advice on the n e u r o - a n a t o m y
Sarah Keer-Keer (Harcourt Publishers) for her help and encouragement
CONTENTS
Introduction 1
Spinal accessory nerve 3
Brachial plexus 4
Musculocutaneous nerve 12
Axillary nerve 14
Radial nerve 16
Median nerve 24
Ulnar nerve 30
Lumbosacral plexus 37
Nerves of the lower limb 38
Dermatomes 56
Nerves and root supply of muscles 60
Commonly tested movements 62
INTRODUCTION
This atlas is intended as a guide to the examination of patients with lesions of peripheral
nerves and nerve roots.
These examinations should, if possible, be conducted in a quiet room where patient
and examiner will be free from distraction. For both motor and sensory testing it is
important that the patient should first be warm. The nature and object of the tests should
be explained to the patient so that his interest and co-operation are secured. If either
shows signs of fatigue, the session should be discontinued and resumed later.
Motor testing
A muscle may act as a prime mover, as a fixator, as an antagonist, or as a synergist. Thus, flexor
carpi ulnaris acts as a prime mover when it flexes and adducts the wrist; as a ftxalor when it
immobilises the pisiform bone during contraction of the adductor digiti minimi; as an
antagonist when it resists extension of the wrist; and as a synergist when the digits, but not
the wrists, are extended.
As far as possible the action of each muscle should be observed separately and a note
made of those in which power has been retained as well as of those that are weak or
paralysed. It is usual to examine the power of a muscle in relation to the movement of a
single joint. It has long been customary to use a 0 to 5 scale for recording muscle power,
but it is generally recognised that subdivision of grade 4 may be helpful.
0 No contraction
1 Flicker or trace of contraction
2 Active movement, with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and resistance
5 Normal power
Grades 4-, 4 and 4+. may be used to indicate movement against slight, moderate and
strong resistance respectively.
The models employed in this work were not chosen because they showed unusual
muscular development; the ease with which the contraction of muscles is identified varies
with the build of the patient, and it is essential that the examiner should both look for and
endeavour to feel the contraction of an accessible muscle and/or the movement of its
tendon. In most of the illustrations the optimum point for palpation has been marked.
Muscles have been arranged in the order of the origin of their motor supply from nerve
trunks, which is convenient in many examinations. Usually only one method of testing
each muscle is shown but, where necessary, multiple illustrations have been included if a
muscle has more than one important action. The examiner should apply the tests as they
are illustrated, because the techniques shown will eliminate many of the traps for the
inexperienced provided by 'trick' movements. It should be noted that each of the methods
used tests, as a rule, the action of muscles at a single joint.
When testing a movement, the limb should be firmly supported proximal to the relevant
joint, so that the test is confined to the chosen muscle group and does not require the
patient to fix the limb proximally by muscle contraction. In this book, this principle is
SPINAL ACCESSORY NERVE
C6
POSTERIOR CORD LATERAL CORD
Pectoralis minor C7
BRACHIAL PLEXUS
Musculocutaneous nerve
Axillary nerve T1
RADIAL NERVE
Medial pectoral nerve
MEDIAN NERVE Lateral pectoral nerve
to latissimus dorsi
Fig. 3 Diagram of the brachial plexus, its branches and the muscles which they supply.
BRACHIAL PLEXUS 5
Fig. 4 The approximate area within which sensory changes may be found in complete
lesions of the brachial plexus (C5, C6, C7, C8, T1).
Fig. 5 The approximate area within which sensory changes may be found in lesions of the
upper roots (C5.C6) of the brachial plexus.
6 BRACHIAL PLEXUS
Fig. 6 The approximate area within which sensory changes may be found in lesions of the
lower roots (C8, T1) of the brachial plexus.
BRACHIAL PLEXUS 7
Fig. 9 Pectoralis Major; Clavicular Head (Lateral pectoral nerve; C5, C6)
The upper arm is above the horizontal and the patient is pushing forward against the
examiner's hand, Arrow, the clavicular head of pectoralis major can be seen and felt.
Fig. 10 Pectoraiis Major: Sternocostal Head {Lateral and medial pectoral nerves; C6, C7,
C8)
The patient is adducting the upper arm against resistance.
Arrow: the sterno-costal head can be seen and felt.
BRACHIAL PLEXUS 9
Coracobrachialis
MUSCULOCUTANEOUS
NERVE
Biceps
Brachialis
Fig. 16 Diagram of the musculocutaneous nerve, its major cutaneous branch and the
muscles which it supplies.
MUSCULOTANEOUS NERVE 13
Fig. 17 The approximate area within which sensory changes may be found in lesions of
the musculocutaneous nerve. (The distribution of the lateral cutaneous nerve of the
forearm.)
AXILLARY NERVE
Deltoid
UPPER CUTANEOUS
NERVE OF THE ARM RADIAL NERVE
Teres minor
Fig. 19 Diagram of the axillary nerve, its major cutaneous branch and the muscles which
it supplies.
Fig. 20 The approximate area within which sensory changes may be found in lesions of
the axillary nerve.
AXILLARY NERVE 15
AXILLARY NERVE
RADIAL NERVE
Brachioradialis
Extensor digitorum
Extensor digiti minimi
Abductor pollias longus
Extensor pollicis longus
Extensor pollicis brevis
Extensor indicis
Fig. 23 Diagram of the radial nerve, its major cutaneous branch and the muscles which it
supplies.
RADIAL NERVE 17
Fig. 24 The approximate area within which sensory changes may be found in high lesions
of the radial nerve {above the origin of the posterior cutaneous nerves of the arm and
forearm). The average area is usually considerably smaller, and absence of sensory changes
has been recorded.
Fig. 25 The approximate area within which sensory changes may be found in lesions of
the radial nerve above the elbow joint and below the origin of the posterior cutaneous
nerve of the forearm. (The distribution of the superficial terminal branch of the radiai
nerve.) Usual area shaded, with dark blue line; light blue line* show small and large areas.
18 RADIAL NERVE
MEDIAN NERVE
Pronator teres
Flexor carpi radialis
Palmaris longus ANTERIOR INTEROSSEOUS NERVE
Flexor digitorum superficialis
Pronator quadratus
Palmar branch
Motor Sensory
Flexor retinaculum
Abductor pollis brevis
Flexor pollicis brevis
Opponens pollicis
First lumbrical
Second lumbrical
Fig. 35 Diagram of the median nerve, its cutaneous branches and the muscles which it
supplies. Note: the white rectangle signifies that the muscle indicated receives a part of its
nerve supply from another peripheral nerve (cf. Figs. 45, 57 and 58).
MEDIAN NERVE 25
Fig. 36 The approximate areas within which sensory changes may be found in lesions of
the median nerve in: A the forearm, B the carpal tunnel.
26 MEDIAN NERVE
Fig. 40 Flexor Digitorum Profundus I and II (Anterior interosseous nerve; C7, C8)
The patient is flexing the distal phalanx of the index finger against resistance with the
middle phalanx fixed.
28 MEDIAN NERVE
Fig. 44 1st Lumbrical-lnterosseous Muscle (Median and ulnar nerves; C8, T1)
The patient is extending the finger at the proximal interphalangeal joint against
resistance with the metacarpophalangeal joint hyperextended and fixed.
ULNAR NERVE
ULNAR NERVE
Palmar cutaneous
branch
Deep motor branch
Flexor carpi ulnaris
Superficial terminal
branches
- Flexor digitorum
profundus III & IV
MEDIAL CUTANEOUS
NERVE OF THE
FOREARM
Motor
Adductor pollicis
Flexor pollicis brevis Abductor
Opponens digiti minimi
Flexor
1st Dorsal interosseous
Fig. 45 Diagram of the ulnar nerve, its cutaneous branches and the muscles which it
supplies.
ULNAR NERVE 31
Fig. 46 The approximate areas within which sensory changes may be found in lesions of
the ulnar nerve: A above the origin of the dorsal cutaneous branch, B below the origin of
the dorsal cutaneous branch and above the origin of the palmar branch, C below the
origin of the palmar branch.
32 ULNAR NERVE
Fig. 47 The approximate area within which sensory changes may be found in lesions of
the medial cutaneous nerve of the forearm.
seen even when abductor digiti minimi is paralysed (see also Fig. 49).
ULNAR NERVE 33
Fig. 50 Flexor Digitorum Profundus III and IV (Ulnar nerve; C7, C8)
The patient is flexing the distal interphalangeal joint against resistance while the middle
phalanx is fixed.
34 ULNAR NERVE
Iliohypogastric nerve
Ilioinguinal nerve
Psoas muscle
To iliacus
Genitofemoral nerve
FEMORAL NERVE
Pudendal nerve
Nerve to
levator ani and
Superior and external sphincter
inferior gluteal nerves
Perineal nerve
Dorsal nerve of
SCIATIC NERVE penis or clitoris
Fig. 56 Diagram of the lumbosacral plexus, its branches and the muscles which they supply.
NERVES OF THE LOWER LIMB
Iliacus
FEMORAL NERVE
OBTURATOR NERVE
LATERAL CUTANEOUS
NERVE OF THE THIGH
Cutaneous branch
Adductor brevis
MEDIAL CUTANEOUS
NERVE OF THE THIGH
Adductor longus
Rectus femoris
Quadriceps Vastus lateralis
femoris Vastus intermedius Gracilis
Vastus medialis
Peroneus tertius
Gluteus medius
Gluteus minimus
TIBIAL NERVE
COMMON PERONEAL NERVE
Tibialis posterior
TIBIAL NERVE
SURAL NERVE
CALCANEAL BRANCH
LATERAL PLANTAR NERVE to:
MEDIAL PLANTAR NERVE to Abductor digiti minimi
Abductor hallucis Flexor digiti minimi
Flexor digitorurn brevis Adductor hallucis
Flexor digitorum brevis Interossei
Cutaneous branches Cutaneous branches
Fig. 58 Diagram of the nerves on the posterior aspect of the lower limb, their cutaneous
branches and the muscles which they supply.
40 NERVES OF THE LOWER LIMB
Fig. 59 The approximate area within which sensory changes may be found in lesions of
the lateral cutaneous nerve of the thigh. Usual area shaded, with dark blue line; large
area indicated with light blue line.
Fig. 60 The approximate area within which sensory changes may be found in lesions of
the femoral nerve. (The distribution of the intermediate and medial cutaneous nerves of
the thigh and the saphenous nerve.)
NERVES OF THE LOWER LIMB 41
Fig. 61 The approximate area within which sensory changes may be found in lesions of
the obturator nerve.
Fig. 62 The approximate area within which sensory changes may be found in lesions of
the posterior cutaneous nerve of the thigh.
42 NERVES OF THE LOWER LIMB
Fig. 63 The approximate area within which sensory changes may be found in lesions of
the trunk of the sciatic nerve. (Modified from M.R.C. Special Report No. 54, 1920.)
Fig. 64 The approximate area within which sensory changes may be found in lesions of
both the sciatic and the posterior cutaneous nerve of the thigh.
NERVES OF THE LOWER LIMB 43
Fig. 65 The approximate area within which sensory changes may be found in lesions of
the common peroneal nerve above the origin of the superficial peroneal nerve. (Modified
from M.R.C. Special Report No. 54, 1920.)
Fig. 66 The approximate area within which sensory changes may be found in lesions of
the deep peroneal nerve.
44 NERVES OF THE LOWER LIMB
Fig. 67 The approximate area within which sensory changes may be found in lesions of
the sural nerve.
Fig. 68 The approximate area within which sensory changes may be found in lesions of
the tibial nerve. (Modified from M.R.C Special Report No. 54, 1920.)
NERVES OF THE LOWER LIMB 45
MEDIAL PLANTAR
NERVE
SURAL NERVE
CALCANEAL NERVE
Fig. 69 The approximate areas supplied by the cutaneous nerves to the sole of the foot.
46 NERVES OF THE LOWER LIMB
Fig. 70 Iliopsoas (Branches from L1, 2 and 3 spinal nerves and femoral nerve; L1, L2, L3)
The patient is flexing the thigh at the hip against resistance with the leg flexed at the
knee and hip.
Fig. 73 Gluteus Medius and Minimus (Superior gluteal nerve; L4, L5, S1)
The patient lies on his back and is internally rotating the thigh against resistance with the
limb flexed at the hip and knee.
48 NERVES OF THE LOWER LIMB
Fig. 74 Gluteus Medius and Minimus and Tensor Fasciae Latae (Superior gluteal nerve; L4,
L5, S1)
The patient lies on his back with the leg extended and is abducting the limb against
resistance. Arrows: the muscle bellies can be felt and sometimes seen.
Fig. 82 Small muscles of the foot (medial and lateral plantar nerves; S1, S2)
The patient is cupping the sole of the foot; the small muscles can be felt and sometimes
seen.
Fig. 87 Peroneus Longus and Brevis (Superficial peroneal nerve; L5, S1)
The patient is everting the foot against resistance. Upper arrow: the tendon of peroneus
brevis. Lower arrow: the tendon of peroneus longus.
DERMATOMES
Fig. 88-91 show the approximate cutaneous areas supplied by each spinal root. There is
considerable variation and overlap between dermatomes, so tnat an isolated root lesion
results in a much smaller area of sensory impairment than is indicated in these diagrams.
This variation also applies to the innervation of the fingers, but the thumb is usually
supplied by C6 and the little finger usually by C8 (see Inouye and Buchthal (1977) Brain
100: 731-748).The heavy axial lines are usually more consistent, showing the boundary
between non consecutive dermatomes.
DERMATOMES 57
The list given below does not include all the muscles innervated by these nerves, but only
those more commonly tested, either clinically or electrically, and shows the order of
innervation.
Brachial Plexus
Rhomboids C4,C5
Serratus anterior C5, C6, C7
Pectoralis major
Clavicular C5, C6
Sternal C6, C7, C8
Supraspinatus C5, C6
Infraspinatus C5, C6
Latissimus dorsi C6, C7, C8
Teres major C5, C6, C7
Axillary Nerve
Deltoid C5, C6
Musculocutaneous Nerve
Biceps C5, C6
Brachialis C5, C6
Radial Nerve
Long head
Triceps Lateral head C6, C7, C8
Medial head
Brachioradialis C5, C6
Extensor carpi radialis longus C5, C6
Median Nerve
Pronator teres C6, C7
Flexor carpi radialis C6, C7
Flexor digitorum superficial C7, C8, T1
Abductor poilicis brevis C8, T1
Flexor pollicis brevis* C8, T1
Opponens pollicis C8, T1
Lumbricals I & II C8, T1
NERVES AND MAIN ROOT SUPPLY OF MUSCLES 61
Ulnar Nerve
Flexor carpi ulnaris C7, C8, T1
Flexor digitorum profundus III & IV C7, C8
Hypothenar muscles C8, T1
Adductor pollicis C8, T1
Flexor pollicis brevis C8, T1
Palmar interossei C8, T1
Dorsal interossei C8, T1
Lumbricals III & IV CS, T1
Femoral Nerve
Iliopsoas L1, L2, L3
Rectus femoris
Vastus lateralis Quadriceps L2, L3, L4
Vastus intermedium femoris
Vastus medialis
Obturator Nerve
Adductor longus L2, L3, L4
Adductor magnus
*Flexor pollicis brevis is often supplied wholly or partially by the ulnar nerve.
COMMONLY TESTED MOVEMENTS
Upper limb
Shoulder abduction ++ C5 Axillary Deltoid
Elbow flexion C5/6 + Musculocutaneous Biceps
C6 + Radial Brachioradialis
Elbow extension + C7 + Radial Triceps
Radial wrist extension + C6 Radial Extensor carpi
radialislongus
Finger extension + C7 Posterior Extensor
interosseus nerve digitorum
communis
Finger flexion C8 + Anterior Flexor pollicis
interosseus nerve longus + Flexor
digitorum
profundus
{index)
Ulnar Flexor digitorum
profundus
(ring + little)
Finger abduction ++ T1 Ulnar First dorsal
interosseous
T1 Median Abductor pollicis
brevis
Lower limb
Hip flexion ++ L1/2 Iliopsoas
Hip adduction L2/3 + Obturator Adductors
Hip extension L5/S1 Sciatic Gluteus
The table shows some commonly tested movements, the principal muscle involved with its
roots and nerve supply. The column headed UMN indicates those movements which are
preferentially weak in upper motor neuron lesions.